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:NOTE: PULL ALL PER1VI� S (SEPTIC, WELL, ETC...) n,,.,KE COPIESFORFILE <br /> ICI)%S:an of <br /> LAND USE REPORT APP# <br /> EHD RECEIVED APP.REFERRAL: 5,1 <br /> t)I COMPLETE & SUBMIT BY <br /> DATE DATE <br /> ATTN: e <br /> SITE ADDRESS: I 1 I—I I �y�✓ �! r rr^^� �` `�d r <br /> In completing the Land Use investigation, draw all Public Health factors on the exhibit (i.e.: sewage disposal, <br /> water supplies, etc...). Where necessary, on an attached piece of plain paper, draw completed map of area <br /> showing population density, location of house,wind direction, etc.... <br /> Public water: Public sewage: <br /> SUMMARY OR COMMENTS: <br /> 00,V1-;)lT10Vz, TO /H�51 <br /> T <br /> I recommend: Approval Denial Continuance Inspector's Signature l., <br /> Supervisor/Lead Senior Comments: <br /> C <br /> SUPERVISOR/LEAD SENIOR APPROVAL: <br /> Oa I/CHECK OFF LIST: _Proofread report? _Correct LAND USE#? <br /> En 06 06 Rev 1199 Correct CONDITION(S)? _Logged in LAND USE BOOK? <br />